HospitalInspections.org

Based on record review, and interviews, the facility registered nurse (RN) failed to supervise the nursing care in accordance with patient safety needs for 1 (Patient #1) of 10 patients reviewed. Patient #1 had been identified as high risk for falls after her left hip procedures. On the evening of 06/22/2025, staff failed to activate an alarm in the patient's room. Later that shift, Patient #1 fell in her room, broke her right hip, and required surgical intervention.

Findings included:

During an interview and record on 9/3/25 at 10:00 AM, Personnel A stated Patient #1 was found on the floor in her room at 5:50 AM on 6/23/25. She stated Patient #1's bed alarm had not been set as required to alert staff if she was attempting to exit the bed. Personnel A stated Patient #1's bed alarm should have been activated as she was a "huge fall risk." The reason the bed alarm had not been activated was unknown.

Record review of Patient #1's orthopaedic surgery consultation note, dated 6/16/25, reflected she was an 83-year-old with a past medical history including status post left hip arthroplasty on 6/3/25. She presented to the emergency room on 6/16/25 after a fall at home with a left prosthetic hip dislocation and closed fractures of the left greater trochanter and posterior acetabular wall. She was admitted for a closed reduction under anesthesia, evaluation of fractures, and overall post reduction stability of the hip.

Record review of Patient #1's Safety Risk nurse's notes dated 6/22/25 at 7:39 PM revealed she had a history of falls, used ambulatory aids, and her Morse Fall Scale score was "85-High Risk". Interventions included, Bed/chair alarm; Assistive Devices; Gait Belt; and low bed.

Record review of Patient #1's Orthopaedic Surgery consulting Physician Note dated 6/23/25 at 2:09 PM revealed, "1. Fracture of femoral neck, right ... Patient had a ground-level fall when ambulating after closed reduction of left hip prosthesis. CT scan was reviewed after the fall demonstrating persistent reduction of left hip with new right femur neck fracture. Treatment options were discussed at length with patient and family. Diagnosis and imaging reviewed. Plan is to proceed with surgery for partial hip replacement ...".

Record review of the facility's Patient Fall Prevention policy, dated October 2021 revealed: " ... Policy: A. All patients will be evaluated for fall potential through completion of the appropriate Falls Risk Assessment. This will occur during the admission assessment process; initial, daily nursing assessment; at minimum of once per shift; following a change in medical condition and/or level of care; and post fall. B. Based on the level of fall risk, nursing interventions will be initiated and will be captured on the patient's plan of care. C. Regardless of risk stratification, standard of care fall prevention elements will be implemented on all patients.

Record Review of the facility's Morse Fall Risk Assessment tool, Updated 11/1/24 revealed the following interventions based on the patient's fall risk

High Risk 45+
oAll low and medium risk interventions
oBed/chair Posey alarm at all times (verify connection to call light)
oPatient to be accompanied at all times when out of bed or chair
oPlace patient close to nursing station if possible
oPlace fall risk indication/signage outside patient door